What’s New in Research – February 2018

Geography Matters: Prescribing Patterns for Opioids in Dermatology

Opioid Claims by State. Shaded by number of opioid claims per 1000 Medicare beneficiaries for 2014.

A new study suggests that opioid prescribing is not widespread among dermatologists, but opportunities exist in concentrated areas to reduce their use. The study appears online Feb. 7 in JAMA Dermatology.

“A small number of dermatologists account for a large percentage of the prescriptions. And it’s concentrated among dermatology surgeons, who are likely giving a standard prescription for a four-day course of opioids after surgery,” said Arash Mostaghimi, MD, MPA, MPH, Director of Inpatient Service in the department of Dermatology at Brigham and Women’s Hospital. He led the study with colleagues from Harvard Medical School and Tufts University School of Medicine.

The researchers used 2014 Medicare Part D prescriber data to evaluate opioid prescriptions by US dermatologists. While they found that opioid prescriptions by dermatologists were few and concentrated in surgical practices, they also found higher rates of opioid prescribing among dermatologists in Southern states. Of the top 115 of prescribers, 108 (93.9 percent) worked in a surgical practice and 83 (72.2 percent) had practices in Southern states.

Of 12,537 dermatologists studied, 42.3 percent had no opioid prescriptions filled by Medicare patients and another 43.1 percent had 1 to 10 prescriptions filled. But 14.5 percent of dermatologists had more than 10 opioid prescriptions filled; these patients received on average one prescription for 4.4 days.

Based on existing literature about opioid use for pain control, particularly in elderly patients, the researchers projected that this use in dermatology could place up to 7,600 Medicare beneficiaries annually at risk of continuing to use opioids 1 year after their prescription, up to 22,800 at risk for gastrointestinal or central nervous system side effects, and close to 1,000 at risk for fractures.

“These numbers should remind us of the importance of emphasizing nonopioid pain medications after surgery in dermatology,” said Mostaghimi. “As dermatologists, we need to revisit habitual post-operative prescribing of opioids. By reducing the number of opioids we prescribe, we may be able to help reduce the number of addictions and adverse events by the thousands.”

Adopting practices saw greater revenue and higher rates of returning patients, but practices caring for the underserved had lower rates of adoption.

In 2011, Medicare introduced the annual wellness visit –a yearly check-up for Medicare beneficiaries at no cost to the patient – but many practices have been slow to offer the visits. A new study by investigators from Brigham and Women’s Hospital examines why some practices have adopted these visits while others have not. The team finds overall that practices caring for the underserved had lower rates of adoption. But practices that did offer the visits saw increased revenue and stability of patient assignment – that is, patients were more likely to stay with the practice for a given three-year time period. Their results are published in the February issue of Health Affairs.

“Practices that adopted annual wellness visits saw increased revenue, yet half of all practices are missing out on these benefits—particularly practices that disproportionately care for medically and socially complex patients,” wrote author Ishani Ganguli, MD, MPH, a researcher and physician in the Division of General Internal Medicine and Primary Care. “For these gains to be shared more equitably, policy makers might encourage the use of annual wellness visits through mechanisms adapted to underserved populations and the practices that serve them.”

Medicare’s annual wellness visit was introduced under the Affordable Care Act (ACA) and is designed to promote evidence-based preventive care, including screening for depression and risk of falls. To better understand the ability and motivations of practices to adopt these wellness visits, the researchers examined national Medicare billing data collected from 2008 to 2015 for a randomly selected sample of Medicare beneficiaries. They examined visit rates, practice revenue and the population of patients served by each practice.

The research team found that roughly half (51.2 percent) of practices provided no annual wellness visits in 2015, while 23.1 percent provided these visits to at least a quarter of their eligible beneficiaries. Visit rates were lower in practices that cared for the historically underserved, including racial minorities and those living in more rural settings. Practices that adopted the annual wellness visit generated greater primary care visit revenue, saw greater stability of patient assignment, and brought in patients who were slightly healthier, on average.

The team also found that small and large practices had similar rates of adoption.

“What small practices lack in resources, they may make up for in agility,” wrote Ganguli. “Adoption may require no more than a single, determined clinician.”

The research was supported in part by a grant from the National Institute on Aging of the National Institutes of Health (Grant No. P01 AG032952).

Study finds two branches work synergistically in pulmonary inflammation.

Frozen sections from the lungs of wild-type and Pla2g5-null mice naıve or treated with Alternaria for 10 days were stained for IL-33 (red), SPC (green) and nuclei (blue). Original magnification 40x.Sizebar50mm. Image courtesy of Sachin Samuchiwal

A new study by researchers from Brigham and Women’s Hospital identifies mediators that are involved in activating lung inflammation. In particular, the team investigated the role of Pla2g5, a lipid-generating enzyme that activates large white blood cells known as macrophages. They show that Pla2g5 plays two important roles: driving the release of a major cytokine by macrophages, and producing free fatty acids (FFAs) which can directly drive the activation of Type 2 innate lymphoid cells (ILC2s) – a key player involved in lung inflammation. Their results are published in Mucosal Immunology.

“The mechanism we describe is like two arms both acting synergistically to activate ILC2s,” said author Sachin Kumar Samuchiwal, PhD, of the Division of Rheumatology, Immunology and Allergy at BWH. “One arm is the production of IL-33 from macrophages, which is diminished by deletion of Pla2g5. The second arm is the production of FFAs, specifically linoleic acid and oleic acid, by Pla2g5. Both regulate the activati
on of ILC2s and increase inflammation in the lungs.”

Previous studies have shown that ILC2s can promote pulmonary inflammation which is critical to disease such as asthma. Macrophages produce a major cytokine in the lungs, interleukin-33 (IL-33), which has been shown to activate ILC2s and lead to subsequent inflammation. However, the exact steps and molecular players that form the pathways connecting Pla2g5 in macrophages and its associated mediators were unknown.

To begin to tease out these players, the researchers used a common fungus, Alternaria Alternata, to trigger pulmonary inflammation in both wild-type mice and mice lacking Pla2g5. They found that in the mice lacking the enzyme, there was a reduced expression of IL-33 by macrophages and reduced levels of FFAs, concurrent with a reduced inflammatory response in the lungs. Their results suggest that both IL-33 and FFAs activate ILC2s which in turn leads to allergen-induced pulmonary inflammation.

This is the first time that FFAs have been shown to play a role in the regulation of ILC2-driven lung inflammation, which is a critical component of asthma and other allergic reactions. Tweaking dietary fatty acid compositions is already under consideration to benefit patients with food allergies, and these findings suggest that similar interventions could be potentially fruitful to asthma sufferers as well.

Corresponding author, Barbara Balestrieri, MD, Division of Rheumatology, Immunology and Allergy at BWH, received a patent relating to the subject matter discussed in the study.